Provider Demographics
NPI:1780082933
Name:MARTIN, MAUREEN
Entity type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LAKE ST
Mailing Address - Street 2:UNIT 4R
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-3850
Mailing Address - Country:US
Mailing Address - Phone:914-346-8840
Mailing Address - Fax:
Practice Address - Street 1:11 LAKE ST
Practice Address - Street 2:UNIT 4R
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-3823
Practice Address - Country:US
Practice Address - Phone:914-346-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY872412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist